A Case in Womens Health: Gestational Diabetes Mellitus before, - - PowerPoint PPT Presentation

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A Case in Women’s Health: Gestational Diabetes Mellitus before, during and after pregnancy

3/2/2018

Pilar Bernal de Pheils, RN, MS, FNP, FAAN Elizabeth Harleman, MD Andrea Kuster, MSN, RN, FNP, IBCLC

UCSF CME: Medical Care of Vulnerable and Underserved Populations 2018

Disclosures

• We have nothing to disclose.

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Our Case – Chapter 1: During pregnancy

• 30 y.o. G2P1 presented to PCP for missed menses at 8 weeks

gestation

• Extensive medical problem list, including hx GDM in previous

pregnancy

• Multiple social stressors, including homelessness
• Many strengths: Even when she couldn’t make it to her appts, she

stayed in touch

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GDM: Prevalence

• Complication unique to pregnancy
• 7% of US pregnancies affected
• Racial and ethnic minority groups disproportionately affected
• Latinas in California 8.3% incidence GDM (5.7% white women)
• One of fastest growing pregnancy complications nationally
• Rate of increase mirrors DM2
• Obesity
• Lack of awareness/testing

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GDM: Risks

• In pregnancy
• Macrosomia/Shoulder dystocia/Birth injury
• Neonatal hypoglycemia
• C-section delivery
• Hypertensive disorders (i.e. preeclampsia)
• After pregnancy
• Mom: increased risk (50-70%) of developing DM2
• Baby: increased risk of DM2

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Diagnostic and Management Considerations

• Diagnostic and management considerations
• Who do we test for GDM?
• When do we test?
• What diagnostics we utilize?

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Who is at risk for GDM?

• First-degree relative with diabetes
• High-risk race/ethnicity (e.g., AA, Latino, NA, Asian A, PI)
• History of GDM or pre-diabetes, stillbirth or fetal malformation
• Women with PCOS, Htn, HLD, CVD
• Other clinical conditions associated with insulin resistance (e.g.,
• verweight or obesity, chronic steroid or atypical antipsychotic use,

acanthosis nigricans).

• Physical inactivity

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Gestational Diabetes: When do we test?

• Test for undiagnosed diabetes at the first prenatal

visit in those with risk factors, using standard diagnostic criteria. B

• Test for gestational diabetes mellitus at 24–28

weeks of gestation in pregnant women not previously known to have diabetes. A

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Screening for DM: How do we test?

Initial OB Visit

• Routine: HgA 1C
• At risk: Add FBS
• HgA1C ≥ 5.7% FBS <92 GTT
• FBS≥ 92 ANY Hg A1C Pre-existing pre-gestational diabetes

Routine (24 to 28 W)

• “One-step” 75-g OGTT or
• 2. “Two-step” approach with a 50-g (nonfasting) screen

followed by a 100-g OGTT for those who screen positive

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How Do We Manage GDM?

• Lifestyle change is an essential component of management of

gestational diabetes mellitus and may suffice for the treatment for many women. Medications should be added if needed to achieve glycemic targets. A

• Insulin is the preferred medication for treating hyperglycemia in

gestational diabetes mellitus, as it does not cross the placenta to a measurable extent. Metformin and glyburide may be used, but both cross the placenta to the fetus, with metformin likely crossing to a greater extent than glyburide. All oral agents lack long-term safety

• data. A

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How Do We Manage GDM?

• Metformin, when used to treat polycystic ovary syndrome and

induce ovulation, need not be continued once pregnancy has been

• confirmed. A
• Fasting and postprandial self-monitoring of blood glucose are

recommended in both gestational diabetes mellitus and preexisting diabetes in pregnancy to achieve glycemic control. B

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Clinical Pearls from our case

• Back to our patient and her barriers:
• Challenges with screening
• Obstacles to care

‒ Cultural/religion ‒ Housing and transportation

• Strengths supporting her care
• Patient Centered Care

‒ Continuity of care ‒ Clinic resources/CA State supported resources in pregnancy ‒ Support based on her values/respectful of her decisions

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Our Case – Chapter 2: After the birth

Returns to PCP at 2-3 months post-partum (didn’t f/u with OB)

• Post-partum GTT was ordered by L&D, not done yet
• Breastfeeding frequently, mostly at night, and mom feeding formula

during the day

• Desires Mirena IUD

What are your priorities?

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Clinical Pearls: Start Education and Planning during Pregnancy - Don’t Wait until Post-Partum!

• GDM and life-long risk
• Preview post-partum f/u, importance of weight management

through diet and exercise, and annual f/u with PCP including A1c

• Contraception
• Know the plan before the birth!
• Breastfeeding
• Emphasize additional benefits for mom and baby

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Our Case – Chapter 3: Contemplating another pregnancy

Patient returns to you two years later, contemplating third pregnancy What pre-conception counseling would you do?

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If you take care of women of reproductive age, it’s not a question of whether you provide preconception care, rather it’s a question of what kind of preconception care you are providing.

Joseph Stanford

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Preconception Care for All

• Assess risk
• Health, pregnancy intention, contraception
• Give protection
• Folic acid, immunizations
• Manage conditions
• Diabetes, obesity, hypothyroidism, STI
• Avoid harmful exposures
• Medications, alcohol, tobacco

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Preconception in Diabetes

• Starting at puberty, preconception counseling should be

incorporated into routine diabetes care for all girls of childbearing potential. A

• Family planning should be discussed and effective

contraception should be prescribed and used until a woman is prepared and ready to become pregnant. A

• Preconception counseling should address the importance
• f glycemic control as close to normal as is safely possible,

ideally A1C 6.0-6.5%, to reduce the risk of pregnancy loss and congenital anomalies. B

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Preconception

• Women with preexisting type 1 or type 2 diabetes

who are planning pregnancy or who have become pregnant should be counseled on the risk of development and/or progression of diabetic retinopathy.

• Dilated eye examinations should occur before

pregnancy or in the first trimester, and then patients should be monitored every trimester and for 1 year postpartum as indicated by degree of retinopathy and as recommended by the eye care

• provider. B

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Case continued

• You send a HgBA1C to aid in preconception counseling
• It returns at 8.2%

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Clinical Pearl

Never (almost never) tell a woman with a medical illness she shouldn’t get pregnant.

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Case continued

• After counseling about the risks of birth defects and pregnancy

loss, your patient decides to use contraception until getting her newly diagnosed DM under better control

• What are her options for contraception?

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1 No restriction for the use of the contraceptive method for a woman with that condition 2 Advantages of using the method generally outweigh the theoretical or proven risks 3 Theoretical or proven risks of the method usually

• utweigh the advantages – not usually recommended

unless more appropriate methods are not available or acceptable 4 Unacceptable health risk if the contraceptive method is used by a woman with that condition

U.S. MEC: Categories Example: Smoking and Contraceptive Use

Cu IUD: Copper IUD; LNG-IUD: Levonorgestrel IUD; DMPA: Depo-Medroxyprogesterone Acetate; POPs: Progestin-only pills; CHCs: Combined hormonal contraceptives including pills, patch, and ring

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Diabetes and Contraception

§ This condition is associated with increased risk for adverse health events as a result of pregnancy † This category should be assessed according to the severity of the condition

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Importance of screening for SDH:

TAILORING TREATMENT TO REDUCE DISPARITIES

• Providers should assess social context, including

potential food insecurity, housing stability, and financial barriers, and apply that information to treatment decisions. A

• Patients should be referred to local community

resources when available. B

• Patients should be provided with self-management

support from lay health coaches, navigators, or community health workers when available. A

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Importance of screening for SDH:

TAILORING TREATMENT TO REDUCE DISPARITIES

• Treatment plans should align with the Chronic Care

Model, emphasizing productive interactions between a prepared proactive practice team and an informed activated patient. A

• When feasible, care systems should support team-

based care, community involvement, patient registries, and decision support tools to meet patient needs. B

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ACOG, 2018 Importance of Social Determinants of Health and Cultural Awareness in the Delivery of Reproductive Health Care

• Inquire about and document social and structural determinants of health that may

influence a patient’s health and use of health care such as access to stable housing, access to food and safe drinking water, utility needs, safety in the home and community, immigration status, and employment conditions.

• Maximize referrals to social services to help improve patients’ abilities to fulfill these

needs.

• Provide access to interpreter services for all patient interactions when patient language

is not the clinician’s language.

• Acknowledge that race, institutionalized racism, and other forms of discrimination

serve as social determinants of health.

• Recognize that stereotyping patients based on presumed cultural beliefs can

negatively affect patient interactions, especially when patients’ behaviors are attributed solely to individual choices without recognizing the role of social and structural factors.

• Advocate for policy changes that promote safe and healthy living environments.

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References/Resources

• ACOG Committee Opinion No. 729. (2018). Importance of Social Determinants of Health and Cultural Awareness in the Delivery of

Reproductive Health Care. Obstetrics & Gynecology;131(1):e43-e48.

• American Diabetes Association. Management of diabetes in pregnancy. (2017). Sec. 13. In Standards of Medical Care in Diabetes, Diabetes

Care; 40(Suppl. 1):S114–S119

• Khalife, T., Pettit, J. M., Weiss, B. D. (2015). Caring for Muslim patients who fast during Ramadan. American family physician, 91(9), 641-642.
• Lachance, L., Kelly, R. P., Wilkin, M., Burke, J., & Waddell, S. (2017). Community-Based Efforts to Prevent and Manage Diabetes in Women

Living in Vulnerable Communities. Journal of Community Health, Published online November 13, 2017.

• Omidvar, S., Faramarzi, M., Hajian Tilak, K., & Nasiri Amiri, F. (2018). Associations of psychosocial factors with pregnancy healthy life styles.

PLoS One, 13(1):e0191723

• Gunderson, E.P., Lewis, C.E, Lin, Y., Sorel, M., Gross, M., Sidney, S., Jacobs, D. Jr., Shikany, J.M., & Quesenberry, C.P. (2018). Lactation

duration and progression to diabetes in women across the childbearing years: The 30-year CARDIA study. JAMA Intern Med. doi:10.1001/jamainternmed.2017.7978.Published online January 16, 2018.

• Lactmed Drugs and Lactation Database: https://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm
• Pereira, P.F., Alfenas, R. C., & Araujo, R.M. (2014). Does breastfeeding influence the risk of developing diabetes mellitus in children? A

review of current evidence. J Pediatr (Rio J) 90, 7–15

• Reprotox: https://reprotox.org/
• Standards of Medical Care in Diabetes (2017). Diabetes Care 40, Supplement 1.Accessible online at care.diabetesjournals.org
• U.S. Medical Eligibility Criteria for Contraceptive Use ( https://www.cdc.gov/mmwr/volumes/65/rr /rr6503a1.htm?s_cid=rr6503a1_w) app

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